Apparatus and methods for rapid deployment of tissue anchors

ABSTRACT

In apparatus and methods for rapid deployment of tissue anchors, a tissue manipulation assembly has a pivoting jaw. A needle assembly can be advanced through the launch tube across tissue received between the jaw members of the tissue manipulation assembly. Tissue anchors can be advanced through the needle assembly for securing received tissue. The tissue anchors can be positioned within a reloadable chamber of a control handle disposed outside the patient, then advanced through the needle assembly.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application is a Continuation of U.S. patent application Ser. No.11/118,876, filed Apr. 28, 2005 and now pending, which is aContinuation-in-Part of U.S. patent application Ser. No. 11/070,863,filed Mar. 1, 2005, now U.S. Pat. No. 8,216,252, which isContinuation-in-Part of U.S. patent application Ser. No. 10/955,245,filed Sep. 29, 2004, now U.S. Pat. No. 7,815,672, which is aContinuation-in-Part of U.S. patent application Ser. No. 10/840,950,filed May 7, 2004, now U.S. Pat. No. 8,308,765. These applications andU.S. Pat. No. 7,736,374, are incorporated herein by reference.

BACKGROUND OF THE INVENTION

The present invention relates to methods and apparatus for manipulatingand/or securing tissue. More particularly, the present invention relatesto methods and apparatus for the deployment of tissue anchors used formanipulating and/or securing tissue endoluminally, for instance, to formand/or secure tissue folds or to approximate regions of tissue, etc.

A number of surgical techniques have been developed to treat variousgastrointestinal disorders. One such example of a pervasive disorder ismorbid obesity. Conventional surgical treatment for morbid obesitytypically includes, e.g., bypassing an absorptive surface of the smallintestine, or reducing the stomach size. However, many conventionalsurgical procedures may present numerous life-threatening post-operativecomplications, and may cause atypical diarrhea, electrolytic imbalance,unpredictable weight loss and reflux of nutritious chyme proximal to thesite of the anastomosis.

Furthermore, the sutures or staples that are often used in surgicalprocedures for gastrointestinal disorders typically require extensivetraining by the clinician to achieve competent use, and may concentratesignificant force over a small surface area of the tissue, therebypotentially causing the suture or staple to tear through the tissue.Many of the surgical procedures require regions of tissue within thebody to be approximated towards one another and reliably secured. Thegastrointestinal lumen, for instance, includes four tissue layers, wherethe mucosa layer is the inner-most tissue layer followed by connectivetissue, the muscularis layer, and where the serosa layer is theouter-most tissue layer.

One problem with conventional gastrointestinal reduction systems is thatthe anchors (or staples) should engage at least the muscularis tissuelayer in order to provide a proper foundation. In other words, themucosa and connective tissue layers typically are not strong enough tosustain the tensile loads imposed by normal movement of the stomach wallduring ingestion and processing of food. In particular, these layerstend to stretch elastically rather than firmly hold the anchors (orstaples) in position, and accordingly, the more rigid muscularis and/orserosa layer should ideally be engaged. This problem of capturing themuscularis or serosa layers becomes particularly acute where it isdesired to place an anchor or other apparatus transesophageally ratherthan intra-operatively, since care must be taken in piercing the toughstomach wall not to inadvertently puncture adjacent tissue or organs.

One conventional method for securing anchors within a body lumen to thetissue is to utilize sewing devices to suture the stomach wall intofolds. This procedure typically involves advancing a sewing instrumentthrough the working channel of an endoscope and into the stomach andagainst the stomach wall tissue. The contacted tissue is then typicallydrawn into the sewing instrument where one or more sutures or tags areimplanted to hold the suctioned tissue in a folded condition known as aplication. Another method involves manually creating sutures forsecuring the plication.

One of the problems associated with these types of procedures is thetime and number of intubations needed to perform the various proceduresendoscopically. Another problem is the time required to complete aplication from the surrounding tissue with the body lumen. In the periodof time that a patient is anesthetized, procedures such as for thetreatment of morbid obesity or for GERD must be performed to completion.Accordingly, the placement and securement of the tissue plication shouldideally be relatively quick and performed with a minimal level ofconfidence.

Another problem with conventional methods involves ensuring that thestaple, knotted suture, or clip is secured tightly against the tissueand that the newly created plication will not relax under any slackwhich may be created by slipping staples, knots, or clips. Otherconventional tissue securement devices such as suture anchors, twistties, crimps, etc. are also often used to prevent sutures from slippingthrough tissue. However, many of these types of devices are typicallylarge and unsuitable for low-profile delivery through the body, e.g.,transesophageally.

Moreover, when grasping or clamping onto or upon the layers of tissuewith conventional anchors, sutures, staples, clips, etc., many of thesedevices are configured to be placed only after the tissue has beenplicated and not during the actual plication procedure. Furthermore,placement of multiple clamping elements may be time-consuming and mayrequire multiple tool exchanges for reloading of the clamping apparatuswith anchors, sutures, staples, etc.

BRIEF SUMMARY OF THE INVENTION

An example of a tool which may be utilized for endoluminally accessingtissue may generally comprise a flexible catheter or tubular body whichmay be configured to be sufficiently flexible for advancement into abody lumen, e.g., transorally, percutaneously, laparoscopically, etc.The tubular body may be configured to be torqueable such that when acontrol handle is manipulated and/or rotated by a practitioner fromoutside the patient's body, the longitudinal and/or torquing force istransmitted along the flexible body such that the distal end of the bodyis advanced, withdrawn, or rotated in a corresponding manner.

A tissue manipulation assembly may be located at the distal end of thetubular body and is generally used to contact and form tissue folds. Thetissue manipulation assembly may be connected to the distal end of thetubular body via a pivotable coupling and a lower jaw member may extenddistally from the pivotable coupling with an upper jaw member, in thisexample, pivotably coupled to the lower jaw member via a jaw pivot. Thelocation of the jaw pivot may be positioned at various locations alongthe lower jaw depending upon a number of factors, e.g., the desired sizeof the “bite” or opening for accepting tissue between the jaw members,the amount of closing force between the jaw members, etc. One or bothjaw members may also have a number of protrusions, projections, graspingteeth, textured surfaces, etc., on the surface or surfaces of the jawmembers to facilitate the adherence of tissue therebetween.

A launch tube may extend from the handle, through tubular body, anddistally from the end of tubular body where a distal end of the launchtube is pivotally connected to the upper jaw member at a pivot. A distalportion of the launch tube may be pivoted into position within a channelor groove defined in upper jaw member to facilitate a low-profileconfiguration of the tissue manipulation assembly. When articulated,either via the launch tube or other mechanism, the jaw members may beurged into an open configuration to receive tissue in the jaw openingbetween the jaw members.

In operation, a shape-lockable endoscopic assembly may be advanced intoa patient's stomach per-orally and through the esophagus. Such anendoscopic assembly may generally comprise an endoscopic device, whichmay have a distal portion that may be articulated and steered toposition its distal end anywhere within the stomach. Once desirablyconfigured, the assembly may then be locked or rigidized to maintain itsshape or configuration to allow for procedures to be performed on thetissue utilizing any number of tools delivered therethrough.

The tissue manipulation assembly may be delivered into the patient whilein a low-profile configuration, e.g., transorally, through theshape-lockable endoscopic assembly, through an endoscope, an endoscopicdevice, or directly. Once desirably positioned, the launch tube may beurged proximally via its proximal end at handle. Because the jawassembly pivot and the relative positioning of the upper jaw pivot alonglower jaw member and launch tube pivot along upper jaw member, theproximal movement of the launch tube may effectively articulate upperjaw into an expanded jaw configuration. Proximally urging the launchtube may also urge the lower jaw member to pivot about the assemblypivot and form an angle relative to a longitudinal axis of the tubularbody. The opening of the upper jaw relative to the lower jaw creates ajaw opening for grasping or receiving tissue. Moreover, the tissuemanipulation assembly may also include a stop located adjacent to thejaw assembly pivot or within the pivot itself.

A second tool for initially engaging the tissue region of interest mayalso be deployed and utilized to engage the tissue and to position theengaged tissue between the jaws of the jaw assembly. Any number of toolsmay be used in combination with the tissue manipulation assembly. Oncethe tissue has been engaged between the jaw members, a needle assemblymay be urged through the launch tube to pierce through the graspedtissue. Once the needle assembly has been passed through the engagedtissue, one or more tissue anchors may be deployed for securing thetissue.

If it is desirable to place tissue anchors at multiple locations and/orto place multiple tissue anchors or multiple tissue anchor assemblies ata given location, additional tissue anchors may be advanced through theguide tube and the needle assembly. In one variation, needle assemblieswith pre-loaded tissue anchors are exchanged during a procedure tofacilitate placement of a plurality of tissue anchors. In anothervariation, a single needle assembly is used, and tissue anchors may beadvanced within the needle assembly as desired from outside the patient,e.g., through a control handle having a reloadable chamber. Apparatusand methods for advancing a plurality of tissue anchors within theneedle assembly are described.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A shows a side view of one variation of a tissue manipulationassembly having a flexible body and a handle.

FIG. 1B illustrates a detail side view of a tissue manipulation assemblyin a low-profile configuration connected to the distal end of thetubular body via a pivotable coupling.

FIGS. 2A to 2C illustrate a method for articulating the tissuemanipulation assembly from a low-profile configuration to an openedconfiguration and to a closed jaw configuration for clamping upontissue, respectively.

FIGS. 3A and 3B show detail perspective views of the tissue manipulationassembly in an open and clamped configuration, respectively.

FIG. 4 shows an assembly view of how a needle deployment assembly may beintroduced through a handle and tubular body of the tissue manipulationassembly.

FIG. 5A shows a detailed assembly view of the needle deployment assemblyfrom FIG. 4.

FIG. 5B shows an exploded assembly view of the needle deploymentassembly from FIG. 5A.

FIG. 6 illustrates one example in which a shape-lockable endoscopicassembly may be advanced into a patient's stomach per-orally and throughthe esophagus with a tissue manipulation assembly advanced through afirst lumen and a tissue engagement member advanced through a secondlumen.

FIG. 7 illustrates a tissue manipulation assembly and examples ofvarious tools, which may be used in combination with the tissuemanipulation assembly.

FIGS. 8A to 8D illustrate an example for performing an endoluminaltissue manipulation and securement procedure utilizing a tissuemanipulation assembly in combination with a separate tissue graspingtool within, e.g., a patient's stomach.

FIG. 9A shows one variation where a single tissue fold may be securedbetween tissue anchors using the tissue manipulation assembly.

FIG. 9B shows another variation where two or more tissue folds may besecured between tissue anchors using the tissue manipulation assembly.

FIGS. 10A and 10B illustrate a variation of the tissue manipulationassembly in a perspective and cross-sectional view, respectively, wherea number of reinforcement members or bars may be positioned along thelaunch tube to increase its column strength.

FIGS. 11A and 11B illustrate another variation of the tissuemanipulation assembly in a perspective and cross-sectional view,respectively, where a pull wire may be routed through the launch tube tofacilitate articulation of the launch tube and/or jaw assembly.

FIG. 12 illustrates yet another variation of the tissue manipulationassembly, which may also utilize a pull wire connected directly to thelaunch tube.

FIG. 13 is a schematic view of a reloadable needle deployment assemblyfor use with a tissue manipulation assembly.

FIGS. 14A-14D are, respectively, an isometric view, a top view, aside-sectional view and a detail top view of a control handle for areloadable needle deployment assembly.

FIGS. 15A and 15B are, respectively, a schematic isometric view and aside-sectional view of a magazine clip that may be utilized with avariation of the apparatus of FIGS. 13 and 14.

DETAILED DESCRIPTION OF THE INVENTION

In manipulating tissue or creating tissue folds, a tissue manipulationassembly having a distal end effector may be advanced endoluminally,e.g., transorally, transgastrically, etc., into the patient's body,e.g., the stomach. The tissue may be engaged or grasped, and the engagedtissue may be manipulated by a surgeon or practitioner from outside thepatient's body. Examples of creating and forming tissue plications maybe seen in further detail in U.S. patent application Ser. No. 10/955,245filed Sep. 29, 2004, which has been incorporated herein by referenceabove, as well as U.S. patent application Ser. No. 10/735,030 filed Dec.12, 2003, which is incorporated herein by reference in its entirety.

In engaging, manipulating, and/or securing the tissue, various methodsand devices may be implemented. For instance, tissue securement devicesmay be delivered and positioned via an endoscopic apparatus forcontacting a tissue wall of the gastrointestinal lumen, creating one ormore tissue folds, and deploying one or more tissue anchors through thetissue fold(s). The tissue anchor(s) may be disposed through themuscularis and/or serosa layers of the gastrointestinal lumen.

An illustrative side view of one example of a tool which may be utilizedfor endoluminally accessing tissue is shown in FIG. 1A, which showsassembly 10. The assembly 10 generally comprises a flexible catheter ortubular body 12 which may be configured to be sufficiently flexible foradvancement into a body lumen, e.g., transorally, percutaneously,laparoscopically, etc. Tubular body 12 may be configured to betorqueable through various methods, e.g., utilizing a braided tubularconstruction, such that when handle 16 is manipulated and/or rotated bya practitioner from outside the patient's body, the longitudinal and/ortorquing force is transmitted along body 12 such that the distal end ofbody 12 is advanced, withdrawn, or rotated in a corresponding manner.

Tissue manipulation assembly 14 is located at the distal end of tubularbody 12 and is generally used to contact and form tissue folds, asmentioned above. FIG. 1B shows an illustrative detail side view in whichtissue manipulation assembly 14 may be seen connected to the distal endof tubular body 12 via a pivotable coupling 18. Lower jaw member 20extends distally from the pivotable coupling 18, and upper jaw member22, in this example, may be pivotably coupled to lower jaw member 20 viajaw pivot 26. The location of jaw pivot 26 may be positioned at variouslocations along lower jaw 20 depending upon a number of factors, e.g.,the desired size of the “bite” or opening for accepting tissue betweenthe jaw members, the amount of closing force between the jaw members,etc. One or both jaw members 20, 22 may also have a number ofprotrusions, projections, grasping teeth, textured surfaces, etc., 24 onthe surface or surfaces of the jaw members 20, 22 facing one another tofacilitate the adherence of tissue between the jaw members 20, 22.

Launch tube 28 may extend from handle 16, through tubular body 12, anddistally from the end of tubular body 12 where a distal end of launchtube 28 is pivotally connected to upper jaw member 22 at launch tubepivot 30. A distal portion of launch tube 28 may be pivoted intoposition within a channel or groove defined in upper jaw member 22, tofacilitate a low-profile configuration of tissue manipulation assembly14. When articulated, either via launch tube 28 or other mechanism, asdescribed further below, jaw members 20, 22 may be urged into an openconfiguration to receive tissue in jaw opening 32 between the jawmembers 20, 22.

Launch tube 28 may be advanced from its proximal end at handle 16 suchthat the portion of launch tube 28, which extends distally from body 12,is forced to rotate at hinge or pivot 30 and reconfigure itself suchthat the exposed portion forms a curved or arcuate shape that positionsthe launch tube opening perpendicularly relative to upper jaw member 22.Launch tube 28, or at least the exposed portion of launch tube 28, maybe fabricated from a highly flexible material or it may be fabricated,e.g., from Nitinol tubing material which is adapted to flex, e.g., viacircumferential slots, to permit bending.

FIGS. 2A to 2C illustrate one method for articulating a tissuemanipulation assembly into an opened and closed configuration. As shownin FIG. 2A, the assembly may be delivered into a patient while in alow-profile configuration 40, e.g., transorally, through an endoscope,an endoscopic device, or directly. Once desirably positioned, launchtube 28 may be urged proximally via its proximal end at handle 16.Because of jaw assembly pivot 18 and the relative positioning of upperjaw pivot 26 along lower jaw member 20 and launch tube pivot 30 alongupper jaw member 22, the proximal movement of launch tube 28 mayeffectively articulate upper jaw 22 into an expanded jaw configuration42, as shown in FIG. 2B. Proximally urging launch tube 28 may also urgelower jaw member 20 to pivot about assembly pivot 18 and form an angle,a, relative to a longitudinal axis of tubular body 12. The opening ofupper jaw 22 relative to lower jaw 20 creates jaw opening 32 forgrasping or receiving tissue. Moreover, the tissue manipulation assemblymay also include a stop located adjacent to jaw assembly pivot 18 orwithin the pivot 18 itself.

Once launch tube 28 has been urged proximally, it may be locked intoplace thus locking the jaw configuration as well. Moreover, having thelaunch tube 28 articulate the jaw members 20, 22 in this variationeliminates the need for a separate jaw articulation and/or lockingmechanism. Once the tissue has been pulled or manipulated between jawmembers 20, 22, launch tube 28 may be pushed distally to actuate the jawmembers 20, 22 into a closed, grasping configuration 48, as shown inFIG. 2C, for engagement with the tissue. As launch tube 28 is urgeddistally through body 12, lower jaw member 20 may be maintained at theangle, a, relative to the tissue to further facilitate manipulation ofthe grasped tissue.

Launch tube 28 may further define a flexible portion 44 distally of arigid portion 46. Although launch tube 28 may be fabricated fromdifferent materials having differing flexibilities, it may also befabricated from a single material, as mentioned above, where theflexible portion 44 may configured, e.g., by slotting, to allow forbending of the launch tube 28 in a plane to form a single curved orarcuate section while the rigid section 46 may extend at least partiallyinto tubular body 12 to provide column strength to launch tube 28 whileit is urged distally upon upper jaw member 22 and upon any tissueengaged thereby, as seen in the FIG. 2C.

Once the tissue has been engaged between jaw members 20, 22, a needleassembly may be urged through handle 16 and out through launch tube 28.The needle assembly may pass through lower jaw member 20 via needleassembly opening 50 defined in lower jaw member 20 to pierce through thegrasped tissue. Once the needle assembly has been passed through theengaged tissue, one or more tissue anchors may be deployed for securingthe tissue, as described in further detail in U.S. patent applicationSer. No. 10/955,245, which has been incorporated by reference above.

FIGS. 3A and 3B show detail perspective views of the tissue manipulationassembly. As shown in FIG. 3A, lower jaw member 20 and upper jaw member22 may be seen its open configuration 42 when the launch tube has beenurged proximally. Launch tube channel 52 may also be seen defined withinupper jaw member 22 for providing a space for positioning the launchtube when in the low-profile configuration. Also shown is needleassembly opening 50 defined within lower jaw member 20 for passage ofthe needle assembly therethrough. FIG. 3B shows the assembly in itsclosed jaw configuration where the launch tube has been urged distallyin which it rotates about launch tube pivot 30 such that the opening thelaunch tube become perpendicular relative to the jaw members 20, 22.

Although one particular variation of the jaw members 20, 22 is shown,this is not intended to be limiting in jaw member configuration oroperation. Other variations may include various placement of the jawsrelative to one another, alternative configurations for articulating thejaw members, alternative configurations for the launch tube placement,etc. Other variations are intended to be within the scope of thisdisclosure.

As mentioned above, a needle deployment assembly 60 may be deployedthrough the assembly 10 by introducing needle deployment assembly 60into the handle 16 and through tubular body 12, as shown in the assemblyview of FIG. 4, such that the needle assembly 66 is advanced from thelaunch tube and into or through approximated tissue. Once the needleassembly 66 has been advanced through the tissue, the anchor assembly 68may be deployed or ejected. Anchor assembly 68 is normally positionedwithin the distal portion of tubular sheath 64, which extends fromneedle assembly control or housing 62. Once the anchor assembly 68 hasbeen fully deployed from sheath 64, the spent needle deployment assembly60 may be removed from assembly 10 and another needle deploymentassembly may be introduced without having to remove assembly 10 from thepatient. The length of sheath 64 is such that it may be passed entirelythrough the length of tubular body 12 to enable the deployment of needleassembly 66 into and/or through the tissue.

FIG. 5A shows a detailed assembly view of the needle deployment assembly60 from FIG. 4. In this variation, elongate and flexible sheath orcatheter 64 may extend removably from needle assembly control or housing62. Sheath or catheter 64 and housing 62 may be interconnected viainterlock 70 which may be adapted to allow for the securement as well asthe rapid release of sheath 64 from housing 62 through any number offastening methods, e.g., threaded connection, press-fit, releasable pin,etc. Needle body 72, which may be configured into any one of thevariations described above, may extend from the distal end of sheath 64while maintaining communication between the lumen of sheath 64 andneedle opening 74.

Elongate pusher 76 may comprise a flexible wire or hypotube, which istranslationally disposed within sheath 64 and movably connected withinhousing 62. A proximally-located actuation member 78 may be rotatably orotherwise connected to housing 62 to selectively actuate thetranslational movement of elongate pusher 76 relative to sheath 64 fordeploying the anchors from needle opening 74. Anchor assembly 68 may beseen positioned distally of elongate pusher 76 within sheath 64 fordeployment from sheath 64. Needle assembly guides 80 may also be seenprotruding from housing 62 for guidance through the locking mechanismdescribed above. FIG. 5B shows an exploded assembly view of the needledeployment assembly 60 from FIG. 5A. As seen, sheath 64 may bedisconnected from housing 62 via interlock 70 to reveal the elongatepusher 76 connected to housing 62 and the distal and proximal anchors82, 84, respectively, of anchor assembly 68.

With respect to the anchor assemblies, the types of anchors shown anddescribed are intended to be illustrative and are not limited to thevariations shown. For instance, the tissue anchor variations may alsoinclude “T”-type anchors while other variations may includereconfigurable “basket”-type anchors, which may generally comprise anumber of configurable struts or legs extending between at least twocollars or support members or reconfigurable mesh structures extendingbetween the two collars. Other variations of these or other types ofanchors are also contemplated for use in an anchor assembly. Moreover, asingle type of anchor may be used exclusively in an anchor assembly;alternatively, a combination of different anchor types may be used in ananchor assembly. Furthermore, the different types of cinching or lockingmechanisms are not intended to be limited to any of the particularvariations shown and described but may be utilized in any of thecombinations or varying types of anchors as practicable.

Other variations for the needle assemblies and for the anchors aredescribed in further detail in U.S. patent application Ser. No.10/955,245, which has been incorporated by reference above. Exemplaryreloadable needle assemblies are described below.

In operation when manipulating and securing tissue within a patient'sbody, a separate elongate shaft having a tool on or near the distal endof the shaft may be utilized in conjunction with the tissue manipulationassembly 14. Such tools are generally utilized in endoluminal procedureswhere the tools are delivered through an endoscope. Generally, severaldifferent tools may be utilized for performing a procedureendoluminally.

As illustrated in FIG. 6, one such example is shown in which ashape-lockable endoscopic assembly 90 may be advanced into a patient'sstomach S per-orally and through the esophagus E. Such an endoscopicassembly 90 may generally comprise an endoscopic device, which may havea distal portion which may be articulated and steered to position itsdistal end anywhere within the stomach S. Once desirably configured,assembly 90 may then be locked or rigidized to maintain its shape orconfiguration to allow for procedures to be performed on the tissueutilizing any number of tools delivered through the assembly 90.Shape-lockable assembly 90 and its variations are described in furtherdetail in U.S. patent application Ser. No. 10/734,562 filed Dec. 12,2003, which is incorporated herein by reference in its entirety.

Shape-lockable assembly 90 may be generally comprised of shape-lockableendoscopic body 92 having an articulatable distal portion 96. Theendoscopic body 92 may define at least first and second lumens 98, 100,respectively, through the endoscopic body 92 through which one or moretools may be deployed into the stomach S. Additional lumens may beprovided through shape-lockable endoscopic body 92, such as avisualization lumen 101, through which an endoscope may be positioned toprovide visualization of the region of tissue. Alternatively, an imagersuch as a CCD imager or optical fibers may be provided in lumen 101 toprovide visualization. An optional thin wall sheath 94 may be disposedthrough the patient's mouth, esophagus E, and possibly past thegastroesophageal junction GEJ into the stomach S. Shape-lockable body 92may be advanced through esophagus E (and through sheath 94, if utilized)and into stomach S while disposed in a flexible state.

Distal steerable portion 96 of endoscopic body 92 may be thenarticulated to an orientation, e.g., whereby distal portion 96facilitates engagement of tissue near and/or inferior to the patient'sgastroesophageal junction GEJ. Accordingly, distal steerable portion 96may comprise a number of steering features, as described in furtherdetail in U.S. patent application Ser. No. 10/734,562, incorporatedabove. With distal steerable portion 96 disposed in a desiredconfiguration or orientation, endoscopic body 92 may be reversiblyshape-locked to a rigid state such that the endoscopic body 92 maintainsits position within the stomach S. Various methods and apparatus forrigidizing endoscopic body 92 along its length are also described infurther detail in U.S. patent application Ser. No. 10/734,562,incorporated above.

FIG. 6 shows tissue manipulation assembly 14 having been advancedthrough first lumen 98 and a tissue engagement member 102 positionedupon flexible shaft 104 advanced through second lumen 100. As the tissuewall of a body lumen, such as the stomach, typically comprises an innermucosal layer, connective tissue, the muscularis layer and the serosalayer. To obtain a durable purchase, e.g., in performing a stomachreduction procedure, tissue engagement member 102 may be advanced intocontact with the tissue and preferably engages the tissue F such thatwhen the tissue engagement member 102 is pulled proximally to draw theengaged tissue F between the jaw members 20, 22 of tissue manipulationassembly 14, at least the muscularis tissue layer and the serosa layeris drawn into tissue manipulation assembly 14.

As tissue manipulation assembly 14 may be utilized to grasp and securethe engaged tissue, any number of tools may be utilized with tissuemanipulation assembly 14, e.g., through shape-lockable endoscopic body92, to engage and manipulate the tissue of interest relative to tissuemanipulation assembly 14. FIG. 7 illustrates tissue manipulationassembly 14 upon flexible body 12 with handle 16 and examples of varioustools which may be used in combination with tissue manipulation assembly14.

Turning to FIG. 7, one example of a tool utilizable in combination withtissue manipulation assembly 14 is shown in tissue engagement member 102as a tissue piercing helix or corkscrew structure upon flexible shaft104 (as shown in FIG. 6).

Tissue engagement member 102 may be rotated about its longitudinal axisto engage the tissue of interest by rotating handle 106 located on theproximal end of flexible shaft 104. Alternatively, a tool havingaggressive tissue graspers 108 positioned upon flexible shaft 110 andarticulatable via handle 112 may be utilized in combination with tissuemanipulation assembly 14. Another alternative tool may be tissuegraspers 114 positioned upon flexible shaft 116 and articulatable viahandle 118. Tissue graspers 114 may have atraumatic grasping surfaces.In yet another alternative, an endoscope 122 having optical fibers orimager 120 may be utilized for providing visualization. Endoscope 122may be articulated via handle 124 at its proximal end.

The examples of the various tools as shown and described are intendedmerely to be illustrative of the range of tools which may be usable withassembly 14 and are not intended to be limiting in any manner. Anynumber of other tools may be accordingly utilized and are intended to bewithin the scope of this disclosure.

An example of performing an endoluminal tissue manipulation andsecurement procedure utilizing tissue manipulation assembly 14 incombination with a separate tissue grasping tool within, e.g., apatient's stomach, is illustrated in FIGS. 8A to 8D. As shown in FIG.8A, once shape-lockable endoscopic body 92 has been introduced into thepatient, e.g., trans-orally, trans-anally, percutaneously, etc., anddesirably positioned relative to a tissue region of interest 130,endoscopic body 92 may be rigidized to maintain its configuration withinthe patient body. Alternatively, it may be left in a flexible stateduring the procedure.

The tissue region of interest 130 as well as the procedure may bevisualized through visualization lumen 101 or a separate imager, asdescribed above. In either case, tissue manipulation assembly 14 andtissue engagement member 102 may be advanced distally out fromendoscopic body 92 through their respective lumens 98, 100. Tissueengagement member 102 may be advanced into contact against the tissuesurface, as shown in FIG. 8A, and then rotated via its proximal handleuntil the tissue is engaged. The engaged tissue F may be pulledproximally relative to endoscopic body 92 and tissue manipulationassembly 14 may be actuated via its proximally located handle into anopen expanded jaw configuration for receiving the engaged tissue F, asshown in FIG. 8B.

Alternatively, once the tissue F has been engaged, tissue manipulationassembly 14 may be advanced distally in its open configuration onto theengaged tissue. In yet another variation, tissue engagement member 102may be omitted entirely and tissue manipulation assembly 14 may beutilized alone to grasp onto the tissue region of interest 130. In yetanother alternative, a second tissue manipulation assembly may be usedin combination with tissue manipulation assembly 14.

Turning back to FIG. 8B, tissue manipulation assembly 14 may bearticulated to receive the engaged tissue F. As shown in FIG. 8C, onceengaged tissue F is positioned between jaw members 20, 22, the launchtube may be urged proximally to actuate upper jaw member 22 to grasp orclamp upon the tissue F. Tissue engagement member 102 may be retractedfrom the tissue F or it may be left within the tissue while tissuemanipulation assembly engages and secures the tissue F.

FIG. 8D shows a partial cross-sectional view of the tissue F whileengaged to tissue manipulation assembly 14. Tissue engagement member 102has been omitted from this view only for the sake of clarity. Asmentioned above, member 102 may be left remaining in the tissue F,disengaged from tissue F, or disengaged and removed entirely fromendoscopic body 92, if so desired, and another tool may be advancedthrough lumen 100 to facilitate the procedure. Once jaw members 20, 22have been actuated to clamp or grasp upon tissue F by the launch tube,the launch tube may be automatically positioned into its anchordeployment configuration. The needle assembly may then be urged viamanipulation from its proximal end at handle 16 through the launch tubeto pierce preferably through a dual serosa layer through engaged tissueF and past lower jaw member 20. As described above, the engaged tissue Fpositioned between the jaw members 20, 22 is desirably engaged such thatthe needle body 72, when urged through the tissue F, is disposed throughthe muscularis and/or serosa layers of the engaged tissue F. Once needlebody 72 has passed through tissue F, one or more expandable tissueanchors may be ejected from needle body 72 through needle opening 74.

Because needle body 72 may penetrate the tissue wall twice, it exitswithin the body lumen if utilized within, e.g., the stomach, thusreducing the potential for injury to surrounding organs. As describedabove, needle body 72 may define needle lumen or opening 74 throughwhich an expandable anchor, e.g., distal anchor 82 and/or proximalanchor 84, may be situated during deployment and positioning of theassembly. A single suture or flexible element 132 (or multiple sutureelements) may connect distal anchor 82 and proximal anchor 84 to oneanother and end in terminal loop 134. For instance, element 132 maycomprise various materials such as monofilament, multifilament, or anyother conventional suture material, elastic or elastomeric materials,e.g., rubber, etc.

Once distal anchor 82 has been ejected, needle body 72 may be urgedproximally back through tissue F, where proximal anchor 84 may then beejected from needle body 72 with suture 132 still connecting the twoanchors 82, 84 through tissue F. Alternatively, tissue manipulationassembly 14, with suture 132 still depending therefrom, may bedisengaged from tissue F and the procedure may be repeated at a secondregion of tissue where proximal anchor 84 may then be ejected.

FIG. 9A shows one variation where a single fold F may be secured betweenproximal anchor 82 and distal anchor 84. With both anchors 82, 84disposed externally of the launch tube and suture 132 connecting thetwo, proximal anchor 84 may be urged into contact against tissue F. Asthe anchors are urged against tissue fold F, distal anchor 82 or aportion of suture 132 may be configured to provide any number ofdirectionally translatable locking mechanisms 136 which provide formovement of an anchor along suture 132 in a first direction andpreferably locks, inhibits, or prevents the reverse movement of theanchor back along suture 132.

FIG. 9B shows another variation where at least two folds F₁ and F₂ maybe secured between proximal anchor 82 and distal anchor 84. After theanchors have been ejected from needle body 72, the anchors may beapproximated towards one another over suture 132 thus bringing folds F₁and F₂ towards one another. Although a single tissue fold and a dualfold are shown in these examples, any number of folds or tissue ridgesmay be created using the tools disclosed herein. Moreover, theseexamples are merely intended to be illustrative and not limiting in anyway. In either case, it may be generally desirable to form the tissuefolds such that serosa-to-serosa contact 138 occurs between the layersof secured tissue, although this may not be necessary.

Various examples of cinching devices and methods which may be utilizedwith the tools and devices herein are described in further detail inU.S. patent application Ser. No. 10/840,950 filed May 7, 2004, which hasbeen incorporated herein above.

In using the launch tube as a jaw actuation mechanism, other variationsof the launch tube may be utilized to ensure sufficient strength andforce transmission in tissue manipulation assembly 14 for jaw memberactuation. One such example is shown in the perspective view of FIG.10A, which shows launch tube 44 having a number of reinforcement membersor bars 140 aligned along one or both sides of the launch tube toprovide for additional column strength. Each of the reinforcementmembers 140 may be pivotally attached to launch tube 44 via pivotmembers 144 rotatably secured within pivot channels 142, as seen in thelaunch tube cross-section in FIG. 10B. Moreover, each of the pivotmembers 144 may define cooperating adjacent members relative to oneanother while maintaining contact to allow for the transmission of forcebetween the members 144. Pivot members 144 may be positioned along thelength of the exposed launch tube or a portion of the launch tube;moreover, a single side of the launch tube may have pivot members 144attached thereto. Alternatively, rather than utilizing pivot members,portions of the launch tube itself may be simply thickened to increaseits column strength and force transmission capabilities.

In another variation, as shown in FIG. 11A and the launch tubecross-section in FIG. 11B, a pull wire 152 may be routed through tubularbody 12 and launch tube 44 through a pull wire lumen 150 to provide alaunch tube and jaw actuation mechanism separate from the launch tubeactuation itself. Pull wire 152 may be manipulated via its proximal endat handle 16 by pulling or pushing pull wire 152 to actuate launch tube44 and/or jaw members 20, 22. Alternatively, as seen in FIG. 12, pullwire 152 may be routed through tubular body 12 and connected directly tolaunch tube 44 at pull wire attachment point 154 rather than routing itthrough the launch tube. Again, manipulation of pull wire 152 may beutilized to articulate the launch tube configuration as well as jawmember articulation.

If it is desirable to place tissue anchors at multiple locations and/orto place multiple tissue anchors or multiple tissue anchor assemblies ata given location, additional tissue anchor assemblies, such asadditional anchor assemblies 68, may be deployed through tubular body 12of assembly 10. In one variation, after placement of the first anchorassembly, sheath 64 and housing 62 of needle deployment assembly 60 maybe disconnected from one another at interlock 70. Elongate pusher 76then may be removed from tubular sheath 64. Next, an additional anchorassembly may be loaded into the proximal end of sheath 64 and advancedthrough the sheath with pusher 76 such that the additional anchorassembly is positioned for delivery within needle body 72. Housing 62may be reattached to sheath 64 at interlock 70. This procedure may berepeated as desired to allow for delivery of any number of anchors oranchor assemblies. Advantageously, tubular body 12 and tissuemanipulation assembly 14 need not be removed from the patient duringreloading of sheath 64 with another anchor assembly.

In another variation, after placement of an anchor assembly, the entireneedle deployment assembly 60 may be removed from tubular body 12. Theremoved needle deployment assembly may be reloaded with another anchorassembly, or a replacement needle deployment assembly with a pre-loadedanchor assembly may be utilized in place of the removed needledeployment assembly. The loaded needle deployment assembly then may bereintroduced through tubular body 12 for delivery of the anchorassembly. Again, tubular body 12 and tissue manipulation assembly 14 mayremain within the patient during anchor reloading.

In yet another variation, the needle deployment assembly may bepre-loaded with a plurality of anchors or anchor assemblies, forexample, a plurality of adjacently aligned anchors, as described in U.S.Pat. No. 7,347,863, incorporated herein by reference.

With reference now to FIG. 13, a reloadable variation of the needledeployment assembly is described. In the variation of FIG. 13, theneedle deployment assembly and the tissue manipulation assembly havebeen integrated into a single device. However, it should be understoodthat the assemblies alternatively may comprise separate assemblies thatare coupled together, as with previous variations. In particular, handle16 of assembly 10 and needle assembly control 62 of needle deploymentassembly 60 have been integrated into control handle 200. Flexibletubular body 12 and tissue manipulation assembly 14, as well as tubularsheath 64 and needle assembly 66, extend from control handle 200.

Control handle 200 comprises tubular body 210 having tissue manipulationassembly control mechanism 220 and needle deployment assembly controlmechanism 230. Tissue control mechanism 220 comprises actuable tissuecontrol handle 222, illustratively a scissor-grip control handle, whichmay be actuated to advance or retract launch tube 28 and close or openjaw members 20 and 22 of tissue manipulation assembly 14, as desired.Optional lock 224 may be provided for maintaining the position of tissuecontrol handle 222 and tissue manipulation assembly 14 without requiringa medical practitioner to maintain his or her grip on the tissue controlhandle.

Needle control mechanism 230 comprises actuable needle and anchorcontrol handle 232, illustratively a scissor-grip handle oriented about90° or perpendicular to tissue control handle 222. Handle 232 may beactuated to advance tubular sheath 64 and needle assembly 66, forexample, through guide tube 28 and across jaw members 20 and 22 foranchoring of a tissue fold disposed between the jaw members. Handle 232also may act as a ratchet for advancing elongate pusher 76 throughsheath 64 in order to deploy an anchor assembly disposed within thesheath. Needle control mechanism 230 comprises ratchet release button234 and torsion spring-wound internal ratchet spool 236. Depression ofbutton 234 releases the ratcheting mechanism of ratchet spool 236 thatprecludes proximal retraction of elongate pusher 76, and energy storedin the torsion spring coupled to the spool causes the pusher to beretracted and wrapped or spooled about the spool. Actuation of handle232 while button 234 is depressed may advance sheath 64 and needleassembly 66 relative to tissue manipulation assembly 14, while actuationof the handle with the ratchet mechanism engaged may advance pusher 76relative to the sheath. Alternatively, handle 232 may comprise a detentwhereby initial approximation of the two sides of the scissor-griphandle advances the needle, after which further approximation advancesthe pusher, or vice versa. Alternative actuation mechanisms will beapparent.

Control handle 200 further comprises loading chamber 240 disposed alongtubular body 210 distal of spool 236. Chamber 240 may pass all the waythrough control handle 200 as shown, or may be accessible only from oneside of the chamber. Tubular cartridge 300 containing an anchorassembly, illustratively anchor assembly 68, may be positioned withinchamber 240 when elongate pusher has been retracted proximal of thechamber. Cartridge 300 optionally may comprise flared proximal end 302for properly aligning the cartridge within the chamber, for facilitatingremoval of the cartridge from the chamber and/or for stabilizing thecartridge within the chamber.

Control handle 200 optionally may further comprise centering element 250disposed within chamber 240 for engaging and centering the flaredproximal end 302 of cartridge 300, thereby aligning the lumen ofcartridge 300 with elongate pusher 76. Centering element 250 may beretracted for loading of cartridge 300 by retracting lever 252 disposedalong tubular body 210.

Control handle 200 and assembly 10 may be utilized as follows. Ratchetrelease button 234 may be depressed in order to retract pusher 76 andwind the pusher about spool 236 such that a distal end of the pusher isdisposed proximally of chamber 240. Lever 252 may be retracted toretract optional centering element 250, and cartridge 300 containinganchor assembly 68 may be positioned within chamber 240. Lever 252 thenmay be re-advanced such that centering element 250 engages flaredproximal end 302 of the cartridge.

With anchor assembly 68 disposed in chamber 240, tissue controlmechanism 220 and tissue control handle 222 may be actuated to engagetissue with tissue manipulation assembly 14, as described previously.Handle 222 optionally may be locked into position via lock 224 in orderto free up the medical practitioner's hand after tissue engagement.Next, needle assembly 66 and sheath 64 may be advanced through andacross the engaged tissue by actuating needle and anchor control handle232 of needle deployment assembly control mechanism 230. Button 234 thenmay be released to reengage the ratchet of needle control mechanism 230,and continued actuation of handle 232 then may advance pusher 76.Advancement of the pusher through cartridge 300 and through sheath 64 ofneedle deployment assembly 60, which is disposed within tubular body 12of assembly 10, advances anchor assembly 68 to needle assembly 64 fordeployment of the anchor assembly. Continued ratcheted advancement ofthe pusher deploys the anchor assembly, as described previously.

If it is desired to deploy one or more additional anchors or anchorassemblies, pusher 76 may be retracted by depressing button 234, andempty cartridge 300 may be removed from chamber 240. A loaded cartridgethen may be disposed within the chamber, and the process may be repeatedas many times as desired. It should be understood that, althoughactuation of control handle 200 has been described such that tissue isengaged and the needle assembly is passed through tissue prior toadvancement of the anchor assembly within the needle assembly, thesesteps may be conducted in any order, as desired.

With reference to FIG. 14, a variation of control handle 200 isdescribed. In FIG. 14, anchor and needle control handle 232 of needledeployment assembly control mechanism 230 has been replaced with controlwheel 232′, ratchet release button 234 has been moved to the proximalend of tubular body 210 of handle 200, and lever 252 has been moved tothe top of body 210. As will be apparent, any other alternative controlmechanism or placement of control features may be provided.

FIG. 14 also illustrate exemplary internal workings for control handle200. Ratchet spool 236 comprises ratchet teeth 237 that coact withratchet mechanism 260, as well as central spool 238 around which pusher76 may be wrapped. Spool 236 is coupled to control wheel 232′ across thewall of tubular body 210, such that the spool and control wheel rotatetogether relative to the body. Torsion spring 239 is coupled betweenratchet spool 236 and the wall of tubular body 210. In this variation,clockwise rotation of control wheel 232′ advances pusher 76 and storesenergy in spring 239 that retracts the pusher upon release of ratchetmechanism 260 from ratchet teeth 237 of spool 236.

Ratchet mechanism 260 comprises lever 262 that is pivotably coupled totubular body 210 at pivot 270. Lever 262 comprises proximal extension263 that coacts with ratchet release button 234, as well as distal catch264 that coacts with ratchet teeth 237. Tension spring 266 connectsproximal extension 263 to the proximal end of body 210 such that distalcatch 264 is biased in a distal direction that facilitates ratchetingupon rotation of control wheel 232′. The ratchet may be released byovercoming the distal bias of catch 264 via depression of ratchetrelease button 234.

Tubular body 210 may comprise narrowing 212 between spool 236 andchamber 240 for passage of pusher 76. Pusher 76 may comprise localizedprotrusion or stop 77 a that is configured to abut narrowing 212 andlimit a degree of retraction of the pusher such that the position of thepusher distal of the narrowing is maintained. Pusher 76 also optionallymay comprise expanded distal tip 77 b to facilitate advancement ofanchor assembly 68 through sheath 64 of needle deployment assembly 60disposed within tubular body 12 and launch tube 28 of assembly 10. Aswill be apparent, protrusion 77 a and expanded tip 77 b optionally maybe combined into a single element or omitted.

Pusher 76 passes through lumen 251 of centering element 250, whichcomprises tapered or bullet-nosed distal end 254 configured to engageflared proximal end 302 of cartridge 300. Element 250 is coupled tolever 252 for retracting the element for loading of chamber 240 withcartridge 300.

Since it might be cumbersome or time consuming to advance pusher 76 fromcontrol handle 200 to tissue manipulation assembly 14 via needledeployment assembly control mechanism 230, e.g., via handle 232 or wheel232′, the pusher optionally may be at least partially advanced via amotor. The motor may be electric, e.g., battery operated or operated viaan AC voltage. Whether advanced manually or in a motorized fashion, anygearing ratio may be provided to facilitate advancement of the pusher.For example, a variable gearing ratio may be provided. A first gearingratio may be utilized to provide for course, rapid advancement of thepusher through sheath 64, while a second gearing ratio may be providedfor fine advancement of the pusher and/or the anchor assembly throughneedle assembly 66. Additional and alternative gearing ratios will beapparent.

With reference to FIG. 15, an exemplary magazine clip for use with avariation of control handle 200 is described. In FIG. 15, chamber 240illustratively is accessed from the side and bottom of handle 200.Spring-loaded magazine clip 400 is positioned within chamber 240 throughthe bottom of the chamber.

A plurality of cartridges 300 having anchor assemblies 68 are disposedwithin spring-loaded magazine clip 400 for rapid reloading of needledeployment assembly 60. The cartridges may be provided to the medicalpractitioner pre-loaded within the clip or may be loaded within the clipby the medical practitioner. Clip 400 comprises at least one compressionspring 402 that biases platform 404, and thereby cartridges 300, towardsthe top of the clip. Clip 400 further comprises ejection shield 406 withside opening 408. Shield 406 provides a counterbalance to spring(s) 402that maintains cartridges 300 within clip 400. Empty cartridges may beremoved through side opening 408. Upon removal of an empty cartridge,spring(s) 402 automatically advance platform 404, which advances thenext loaded cartridge 300 in the stack within chamber 240.

In one variation, an empty cartridge 300 is automatically ejected fromclip 400 when the medical practitioner retracts pusher 76 and centeringelement 250. Proximal end 407 of the shield optionally may be flared, asin FIG. 15B, to coact with centering element 250. In another variation,the medical practitioner manually ejects the empty cartridge. Ejectionmechanics may be controlled, for example, by specifying the profile ofshield 406 and/or the coupling of clip 400 to handle 200.

Magazine clip 400 and/or handle 200 optionally may comprise a reservoirfor storing empty cartridges 300. Furthermore, although magazine clip400 illustratively comprises a linear stack of cartridges 300, themagazine alternatively may comprise a revolver having a plurality ofchambers that contain anchor assemblies and/or cartridges. In such avariation, the revolver magazine may be attached to loading chamber 240such that loaded revolver chambers are positioned within, and emptyrevolver chambers are removed from, the loading chamber via a rotarymotion. Additional magazine variations will be apparent.

Although a number of illustrative variations are described above, itwill be apparent to those skilled in the art that various changes andmodifications may be made thereto without departing from the scope ofthe invention. Moreover, although specific configurations andapplications may be shown, it is intended that the various features maybe utilized in various combinations and in various types of proceduresas practicable. It is intended in the appended claims to cover all suchchanges and modifications that fall within the true spirit and scope ofthe invention.

1. Surgical apparatus, comprising: a flexible tube; a handle attached toa first end of the flexible tube; a tissue manipulation assemblyattached to a second end of the flexible tube; a needle assembly movablewithin the flexible tube, with the needle assembly including a hollowneedle attached to an end of a sheath; a pusher in the handle extendibleinto the sheath; a first controller on the handle linked to the tissuemanipulation assembly; and a second controller on the handle foradvancing the needle assembly through the flexible tube, and foradvancing the pusher into the sheath.
 2. The apparatus of claim 1 withat least one of the first controller and the second controllercomprising at least one lever pivotally attached to the handle.
 3. Theapparatus of claim 1 with at least one of the first controller and thesecond controller comprising a scissor grip handle.
 4. The apparatus ofclaim 1 with the handle including a loading chamber for loading a tissueanchor cartridge into the handle.
 5. The apparatus of claim 4 furtherincluding a centering element movable within the handle to center atissue anchor cartridge in the loading chamber.
 6. The apparatus ofclaim 1 further including a release on the handle movable into a firstposition and into a second position, with the second controllercontrolling movement of the needle assembly when the release is in thefirst position, and with the second controller controlling the pusherwhen the release is in the second position.
 7. The apparatus of claim 1with the pusher wound on a ratchet spool biased by a spring into aretracted position wherein the pusher is in a coil entirely within thehandle.
 8. The apparatus of claim 3 wherein the first controllercomprising a first scissor grip handle, and the second controllercomprises a second scissor grip handle oriented at an angle offset fromthe first scissor grip handle.
 9. The apparatus of claim 8 wherein thefirst scissor grip handle is substantially perpendicular to and in frontof the second scissor grip handle.
 10. The apparatus of claim 1 with thetissue manipulation assembly linked to the first controller via a launchtube extending through the flexible tube, and with the needle assemblywithin the launch tube.
 11. The apparatus of claim 1 further comprisinga motor in the handle for advancing the pusher.
 12. The apparatus ofclaim 1 further including a gear mechanism in the handle for advancingthe pusher.
 13. The apparatus of claim 1 with the tissue manipulationassembly including a first jaw member pivotably coupled to the distalend of the flexible tube, a second jaw member pivotably coupled to thefirst jaw member, and a launch tube adapted to urge the first and secondjaw members between a low-profile delivery configuration and an expandedgrasping configuration.
 14. The apparatus of claim 1 with the secondcontroller comprising a control wheel on the handle.
 15. The apparatusof claim 14 with the control wheel comprising a ratchet wheel.
 16. Amethod of securing tissue within a hollow body organ, comprising:loading a chamber of a control handle of a surgical tool with a firsttissue anchor; endoluminally advancing a tissue grasping tool into thehollow body organ; engaging first tissue with the tissue grasping tool;advancing the first tissue anchor to the tissue grasping tool with apusher; securing the engaged first tissue with the first tissue anchor;releasing the secured first tissue and engaging second tissue with thetissue grasping tool; loading the chamber of the control handle of thesurgical tool with a second tissue anchor; advancing the second tissueanchor to the tissue grasping tool with the pusher; and securing theengaged second tissue with the second tissue anchor.
 17. The method ofclaim 16 further including attaching a clip containing multiple tissueanchors onto the control handle.
 18. The method of claim 16 furthercomprising retracting the pusher and loading a third tissue anchor intothe chamber.